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Date ....,,:?-1
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that C D .........S ( dL & ��
has permission to perform .....4� ..... i.�......................(....!¢ ..........
wiring in the building of C) /W v
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Fee.. Lic. No...... al ..... ...................... .................... ..............
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ELECTRICAL INSPECPOR
Check # t 2 Z
Commonwealth of Massachusetts Official Use only
Department of Fire Services Permit No. 16,"?
Occupancy and Fee Checked
TF. BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: hJQ
City or Town of: NORTH ANDOVER To the InslQctor of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 1 O J4 /CaLly V I
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Box)
Purpose of Building
Existing Service
New Service
Utility Authorization No.
Amps Volts Overhead ❑ Undgrd ❑
Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
No. of Meters
Completion of the ollowing table may be waived by the Inspector o Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
AboveIn-
Swimming Pool rnd. [Irnd. ❑
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS I
No. of Zones
No. of Switches /
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat PumpNumber
Totals:
Tons,
KW
. ......... . ....
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Si ns Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:[3.,Anca5-% Y% % Fr,i Floor m-, 2ziXd >F/ l2e
kce—
�_ Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: �O (When required by municipal policy.)
Work to Start: 1'7 Atilt Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the
licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned
certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:)
I cert, under the pains mrd penalties of perjury, that the information on this application is true and complete.
FIRM NAME: (J ieS i w F I ec+(- I G` ^ LIC. NO.: ?W9
Licensee: L 41--j t'r-- hc.G OC 0,4/tt Signatur LIC. NO.:
(Ifapplicable, enter "exempt" i the license number line.) 94-970
Address: nst' 4us. . .-V
Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required
by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's
Owner/Agent
Signature Telephone No. PERMIT FEE: $
The Commonwealth of Massachusetts
Department of Industrial Accidents
•W Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):E lir-e4
Address: Su 1SJ U ad
City/State/Zip: f ki JOv e r Phone #: q7 7 c/C,, 4 ,S—C
Are yo n employer? Check the appropriate box:
1. I am a employer with d
4. ❑ I am a general contractor and I
en}ployees (full and/or part-time).*
have hired the sub -contractors
2. am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] f
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. emodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do eby rte under tl:e pains and penalties of perjury that the information provided above is true and correct
Phone #: e(71— 75/(7 ! y
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
M
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Date. 3.uUC1.....
NORTH
Of 11,
o� TOWN OF NORTH ANDOVER
1 F
' PERMIT FOR GAS INSTALLATION
SSAC NUSES
This certifies that .... Lk
has permission for gas installation
in the buildings of ... ?5.h tat .......... North Andover, Mass.
Fee. 30f%. Lic. No. f!.. h �t ........
GAS INSPECTOR
Check # Z 3
6739
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MASSACHUSETTS UNIFORM APPUCATONFOR PERM TODOGAS FITT]IG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date /0
Building Logations 10 41 CcRT Wigg
Permit # 6.23
-��
y Owner's Name Amount $
y New
Renovation Replacement ❑ Plans Submitted ❑
(Print or type) p `\
Name__ W �1�i�, ��� _ Check one: Certificate Installing Company
Address
L� p' 13 Corp.
— S3 ^!�'i�u.rk�^ �_ � �►AvS� IV�
Partner.usmess a ep one ! 7 Z • �,
Firm/Co.
Name ofLicensed Plumber'or Gas Fitter
FRANOVERAGE
liability Insurance•policy or it's substantial equivalent. Check one:
cked yes, please in ' e the a cove y YesED No�ce policy type
�e b checking the appropriate box.
type of indemnity
Owner's insurance Waiver 13
1•am aware that 0 Bond
the licensee does the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Check one:
er
i hereby certify that all of the details and information I have submitted (or entered) d) in 1 apgent iication� a and accurate to
best of my knowledge and that all plumbing work and installations erformed under Permit Issued for this application will be in the
compliance with all pertinent provisions of the Massac s
as Code and Chapter .I 42 of the General Laws.
By: gnature of Licens d Plumber Or Gas Fitter
Title Plumber
City/Town, ss'3 1
[3 Gas Fitter
icense umber
Master
APPROVED (OFFICE USE ONLY) Journeyman
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Name__ W �1�i�, ��� _ Check one: Certificate Installing Company
Address
L� p' 13 Corp.
— S3 ^!�'i�u.rk�^ �_ � �►AvS� IV�
Partner.usmess a ep one ! 7 Z • �,
Firm/Co.
Name ofLicensed Plumber'or Gas Fitter
FRANOVERAGE
liability Insurance•policy or it's substantial equivalent. Check one:
cked yes, please in ' e the a cove y YesED No�ce policy type
�e b checking the appropriate box.
type of indemnity
Owner's insurance Waiver 13
1•am aware that 0 Bond
the licensee does the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Check one:
er
i hereby certify that all of the details and information I have submitted (or entered) d) in 1 apgent iication� a and accurate to
best of my knowledge and that all plumbing work and installations erformed under Permit Issued for this application will be in the
compliance with all pertinent provisions of the Massac s
as Code and Chapter .I 42 of the General Laws.
By: gnature of Licens d Plumber Or Gas Fitter
Title Plumber
City/Town, ss'3 1
[3 Gas Fitter
icense umber
Master
APPROVED (OFFICE USE ONLY) Journeyman
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'he (,'orrunanwe¢lth of Massachusetts
Department of Industrial Accidents
Off' --e of Investigations
600 Wasjiingion Street
Boston, MA 02111
wM'�v, mass.gos�/dia
Workers' Compensatioa Insurance.A�tid vit. gudders/Ctintractors/Eleciricians/Pium
�Iicant Infornxation hers
------------
Name (B
Address: g � f _� 1)
,�p
city/State/zip:1�x-,-Aj
Phone #: 9 N 2-
mployer? Check the appropriate box:
mployer
71?1
with 4. [ am a o
-----__ ❑ contractor
project (required):
aired
general and I .(
es (full and/or part-time).* have hired the sub-contractorsnstruction
o}e proprietor or Iisted
7,,,
partner_
on the attached sheet ship and have no emp}ovees These sub_coniractors
eIing .
have
working forme in any capacity. workers' comp.
g ❑Demolition
insurance.
[No workers' pomp. insurance S. ❑ We are a on
corporation and its
and
9' ❑ Building a.ddifion
required.] officers have its
3. ❑ I an a homeowner doing all work right of
ht
10 ❑ Electrical repairs or additions
a xem tion
P per MGL
myself. [No. workers' comp, C.
C.
insurance
e 1(4), and we have
I I .[] Plumbing repairs or additions
required] t no
-employees.
P Y s [No .workers
12=❑ Roof repairs
coMp. insurance required.]
Any appficant.that checks box # i must also fill our the section below shov7ng
t
13 ❑ Other
their workers' comPertsation
mmcowners who subniis.t ox affidavit indicatiizg Lie att uuiEi� `'t;i:t+r tid (ham nirr outside canvru iurc
ICanuaetors Thr check this box must attached an
policy inrormation
muni aumnii a new amuavit in_: +� .
additional sheet showing the name of t3 e s b coarractors and their wo rKers' comp, poli�y� inrannation.
am an entpicyer that is providirze worrcers' compensation ion.
n1�enSa$aK iluarance
informadox nr
.f ng employees. Below is the policy and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation otic decla City/Stat„ /Zip,
P y . rMCiL page (showing the policy number and expiration date).
.Failure to secure coverage as required lender Section 25A of MGL C. I52 can lead to the imposition of criminal penalties of
fine up to S11500.00 and/or one-year imprisonmentBeav' as well as civil penalties in the form of a STOP WORK ORDER and a fi
of up to .1250.00 a day against the violator. Be P a
Investigations of the, DIA for insurance coverag.even cation. copy of thisstatement may be forwarded to the ne
Office of
i do iara6,i
`-" — pins ana penalties ofperlurJ' thal the information provided above is true and correct
Official use only. Do not write in this area, to be ennrpL"ed by city or town officiaL
Cite or Town:
Issuilte Authority (circle one): Permit/License #
1. Board of Flealth 2. Building Department 3. City/Tovvn Cierk 4. Electrical inspector 5. Piumbirt�
6. Other m Inspector
Contact Person:
Phone#:
Information and Instructions ...,
Massachusetts General. Laws chapter IS2 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined. as "...every person in the service of another under any contract of hire,
express or implied oral or written."
An en:pinyer is defined as "an individual, partnership; association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and inc)utiiri,g the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maint-nance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an emplover."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withbold the issuanceor
renewal of a license or permttto operate a business or to construct buildings in the commonwealth for -any
applicant who has not produced acceptable evidence of compiiance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its poiitical subdivisions shall
enter into any contract for the performance of pubiic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority,"
kppiicants
Please fill out the workers' compensation affidavit comps-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub -cont =or(s) name(s), address(es) and phone number(s) along with their r—ertificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an'LLCor LLP does have -.
employees, a policy is required_ Be advised that this 2.5davit may be submitted to tine Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign anddate the -affidavit. The affidavitshouid
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Ac cidenls. Should you have any questions regra?-ding the lata or, if you are rcquimd to obtain a workers'
compensation policy, please call the Deparim�nt at the nuanber.listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the'affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit foryou to fill but in the event th.e Office of' investigations has to contact you regarding the applicant:
Please be sure to fill in the permitflicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permi0icense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or Iicenses. A new affidavit must be filled out each
year. Whem a home owner or citizen is obtaining a licenses or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn *leaves etc.) said person is NOT required to complete this affidavit.
The Office of investigations would like to.thank you in advance for your cooperation and should you have any questions,
pease do not hesitate to give us a =11.
The Departrnent's address, telephone and fay, number.
The Commonwealth of Massachusetts
Dt.partment Of€ndustrial .Accidents
Office of LIIveptigations
600'Washdngton Street
Boston; 1A G2111
Tel 4 617-727-4900 ea, -t 406 Qr 1-8777-MASSAFE
Revised 5-26=05
Fax 4 617-72.7-7749
w1mmam.gov/dia